What physical examination is done in a patient with vertigo?

Physical Examination for Vertigo

The physical examination for vertigo must include the Dix-Hallpike maneuver bilaterally to diagnose posterior canal BPPV, followed by the supine roll test if the Dix-Hallpike is negative or shows horizontal nystagmus, along with nystagmus assessment and a focused neurologic examination to distinguish peripheral from central causes. 1

Essential Positional Testing Maneuvers

Dix-Hallpike Maneuver (Gold Standard for Posterior Canal BPPV)

Perform this test bilaterally on every patient with positional vertigo symptoms 1:

• Technique: With patient seated upright, rotate head 45° to one side (aligning the posterior semicircular canal with the sagittal plane), then rapidly move patient to supine position with head extended 20° beyond horizontal, maintaining the 45° rotation 1

• Positive findings indicating posterior canal BPPV include all of the following 1:

  • Torsional (rotatory) and upbeating (toward forehead) nystagmus 1
  • Latency period of 5-20 seconds (rarely up to 60 seconds) between completing the maneuver and symptom onset 1
  • Symptoms and nystagmus that crescendo then resolve within 60 seconds from nystagmus onset 1
  • Subjective vertigo accompanying the nystagmus 1

• Repeat on opposite side to determine which ear is affected or if bilateral involvement exists 1

Supine Roll Test (For Lateral Canal BPPV)

Perform this test if Dix-Hallpike is negative or shows horizontal nystagmus 1:

• With patient supine and head in neutral position, rapidly rotate head 90° to one side, then return to center and rotate 90° to opposite side 1
• Lateral canal BPPV is the second most common type and is frequently missed when clinicians fail to perform this test 1

Nystagmus Assessment

Carefully observe and characterize nystagmus patterns to distinguish peripheral from central causes 2, 3:

• Central warning signs requiring urgent evaluation include 3, 4:

  • Downbeating nystagmus 3
  • Direction-changing nystagmus without head position changes 3
  • Gaze-holding nystagmus 3
  • Baseline nystagmus without provocative maneuvers 3
  • Nystagmus that does not lessen when patient focuses 5

• Peripheral nystagmus characteristics: unidirectional, suppressed by visual fixation, and associated with latency and fatigability 6, 5

HINTS Examination (For Acute Vestibular Syndrome)

When patient presents with continuous vertigo lasting hours to days, perform the HINTS examination to detect stroke 3:

• Head Impulse Test: Abnormal (corrective saccade) suggests peripheral cause; normal suggests central/stroke 3
• Nystagmus assessment: Direction-changing suggests central cause 3
• Test of Skew: Vertical misalignment suggests central cause 3

The HINTS examination has 100% sensitivity for stroke when performed by trained practitioners, compared to only 46% for early MRI 3. Critical caveat: Up to 80% of stroke patients with vertigo may lack focal neurologic deficits 3, 4.

Neurologic Examination

Perform focused neurologic assessment to identify central causes 2, 6:

• Assess for dysarthria, dysmetria, sensory/motor deficits, and cerebellar signs 4, 5
• Test coordination and gait 6, 7
• Evaluate cranial nerves, particularly hearing assessment 2, 6

Otologic Examination

Complete otologic examination including 2:

• Tympanic membrane visualization 2
• Hearing assessment (unilateral hearing loss suggests Menière's disease) 2, 6
• Assessment for tinnitus or aural fullness 2

Orthostatic Vital Signs

Measure blood pressure and heart rate supine and standing to assess for presyncope causes 6, 7:

• Orthostatic hypotension can mimic or coexist with vestibular causes 7
• Presence of syncope excludes peripheral vestibular causes 8

Cardiovascular Examination

Perform cardiac auscultation and assess for arrhythmias 6:

• Cardiac causes can present with dizziness mimicking vertigo 6, 7

Key Contraindications and Modifications

Avoid or modify Dix-Hallpike maneuver in patients with 1:

• Significant vascular disease (vertebrobasilar insufficiency risk) 1
• Severe cervical stenosis, kyphoscoliosis, or limited cervical range of motion 1
• Down syndrome, severe rheumatoid arthritis, cervical radiculopathies 1
• Morbid obesity (may require additional examiner support or special tilting tables) 1

Common Pitfalls to Avoid

• Do not rely solely on patient's description of "dizziness" without performing objective positional testing 2
• Do not assume negative Dix-Hallpike rules out BPPV - the test has only 52% negative predictive value and may need repeating at a separate visit 1
• Do not skip the supine roll test when Dix-Hallpike is negative, as lateral canal BPPV is commonly missed 1, 2
• Do not assume absence of focal neurologic deficits rules out stroke - one-third to two-thirds of stroke patients with vertigo lack focal findings 3